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Full text of "United States Navy Medical News Letter Vol. 32 No. 2, 18 July 1958"

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NavMed 369 




UNITED STATES NA VY 



HDfK^rL 03 




»X^iiii^^^>^SSkiiiiilk&ii:Wii:i.i 







Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Leslie B. Marshall MC USN (RET) - Editor 



Vol. 32 



Friday 18 July 1958 



No. 2 



TABLE OF CONTENTS 



Shock in Myocardial Infarction 2 

Significance of the Serum Amylase Determination . 4 

Treatment of Infectious Mononucleosis 7 

Tuberculosis - A Disease of Old Age 9 

Localized Pulmonary Emphysema of Infancy 12 

Acetazolamide (Diamox) Therapy in Chronic Glaucoma , 14 

Surgery of Portal Cirrhosis of the Liver 16 

Surgical Parotitis 18 

Practical Aspects of a Hearing Conservation Progra'm 19 

From the Note Book 21 

Voluntary Retirement . 23 

Courses for Naval MD Officers - Sponsored by U. S, Army , 23 

Courses for Medical and Dental Officers 24 

Residencies Vacant in Specialties of Allergy and Otolaryngology 25 

Recent Research Reports 26 

DENTAL SECTION 

Anniversary Greetings from the Surgeon General 27 

Practical Methods for Good Dental X-Ray Practice 28 

RESERVE SECTION 

HC Division Participates in Operation Alert 30 

Military Industrial Vision Seminar 30 

Treatment of Chemical *Varfare Casualties 31 

PREVENTIVE MEDICINE SECTION 

Seat Belts in Actual Crashes . 32 

Possible Transmission of Poliomyelitis by Domestic Pets 34 

Ecology of Equine Encephalomyelitis 35 

Fires and Explosions in the Operating Room , 37 

Formulas for Newborn Infants 38 

Statennent on Prophylaxis of Ophthalmia Neonatorum 39 



Medical News Letter, Vol. 32, No. 2 



Shock in Myocardial Infarction 

In evaluating the effects of treatment on the natural prognosis of "shock" 
accompanying myocardial infarction, it is essential to define this type of 
circulatory failure regardless of the possible misuse of the term "shock" 
in this context. The generally accepted clinical pattern in all types of 
shock consists of slightly cyanotic pallor, cold skin, excessive sweating, 
restlessness, weakness, and tachycardia. These signs vary in occurrence 
and intensity. The apparent critical characteristic of the life -endangering 
shock of myocardial infarction is severe prolonged hypotension which may 
occur at the onset of the attack, during the first day, or from the second to 
the fourth day. 

The reported fatality rates in untreated shock of myocardial infarction 
range from 60 to 90%. The variation arises largely from the differences in 
criteria of "severity" and "duration. " The two elements may operate inde- 
pendently or concomitantly in affecting prognosis. For instance, a blood 
pressure that falls to an unobtainable level will represent a threat to life 
if it persists for 15 minutes or even less. A fall in systolic pressure to 
85 mm. Hg. which lasts for 4 hours, if accompanied by such evidence of 
circulatory inadequacy as an hourly renal output of only 10 ml. of urine, 
is equally likely to lead to death. The preinfarction blood pressure appar- 
ently influences the critical level of shock production. Thus, a hyperten- 
sive patient v/ith fixed pressures of over 180/110 mm. Hg. , may enter a 
shocklike state when his pressure falls to 110/70 mm. Hg. , whereas a 
person whose "normal" pressure is 94/60 mm. Hg. may exhibit no appar- 
ent shock with a fall to 80/50 mm. Hg. Fixing an arbitrary critical level 
of blood pressure or duration of hypotension which is applicable in all cases 
is impossible. Accumulated experience and reports in the literature, how- 
ever, indicate that in a normotensive patient, a decrease in systolic blood 
pressure to below 85 mm. Hg which persists for over 1 hour is generally 
accompanied by the other features of shock and, if not treated, denotes a 
poor prognosis. If the hypotension persists over 3 hours, the shock be- 
comes irreversible and 90% of such cases terminate fatally regardless of 
possible transient response to heroic therapy. 

Approximately one -half of all patients exhibiting systolic hypotension 
of 60 to 80 mm. Hg. for one-half hour or less spontaneously recover with- 
out demonstrable ill effects. Hypotension with systolic blood pressure 
levels between 70 and 85 mm. Hg. may be maintained for 12 to 72 hours 
in certain patients who show no other manifestations of shock and who may 
excrete from 200 to 400 ml. of urine daily. However, over 80% of these 
patients, if not treated, develop severe and fatal irreversible shock. 
Attempts at correcting the hypotension are strongly recommended in such 
cases. 

Current knowledge of the basic mechanism of the shock of myocardial in- 
farction and irreversible shock dictates to some degree the therapy employed. 



Medical News Letter, Vol. 32, No. 2 



Two elements leading to hypotension are recognized aa being precipitated 
by myocardial infarction. The first consists of myocardial failure and 
reduced cardiac output. The frequent occurrence of mild to severe pul- 
monary edema and of prolonged circulation rates, as well as ballooning of 
areas of heart muscle as observed by roentgenkymography, clinically 
corroborates this concept. In such cases, administration of oxygen by 
nasal cannula, mask, or tent seems warranted. Digitalis glycosides are 
widely recommended, but whereas no contraindication exists for their use 
in nontoxic doses, they appear to be of little or no imnnediate benefit except 
in atrial flutter or fibrillation. The second element leading to hypotension 
is a peripheral vascular reaction resulting in (a) failure of nnaintenance of 
arterial resistance in the presence of lowered cardiac output, and (b) pos- 
sible decrease of peripheral and visceral venous tone with maintenance of 
constriction of outlet visceral veins resulting in venous pooling as demon- 
strated experimentally in other forms of hypotension by Smith and Hoobler 
and by Weil, et al. 

Irreversible shock is likely to develop if hypotention is not corrected 
within 3 hours. Recovery occurs in only about 10% of such patients treated 
with pressor agents. The causes of irrev-ersible shock are not known, but 
several reasons have been given for the failure of a patient to respond to 
treatment and for the transiency of pressor responses to drugs. These are 
(a) the release of ferritin or vasodepressor substance (VDM) by the hypoxic 
liver, (b) the development of acidosis which diminishes the effects of pressor 
amine drugs and incidentally tends toward precipitation of cardiac arrhyth- 
mias, (c) decreased blood coagulability and formation of multiple thrombi 
in the lungs, brain, and kidney, (d) absorption into the blood of rapidly 
developing bacterial exotoxin from the hypoxic intestinal tract, (e) further 
damage to the myocardium by ischemia and hypoxia as evidenced specifically 
by faulty carbohydrate metabolism of the muscle, and (f) possible adrenal 
secretory insufficiency. In the light of these possible causes, oxygen inhal- 
ation, administration of heparin and of adequate amounts of fluid and carbo- 
hydrate by parenteral or oral routes, use of intestinal antibiotics, e. g. , 
Bacitracin or Polymyxin, and alkalinizing therapy without concomitant 
sodium retention nnay be considered theoretically valuable. Unfortunately, 
none of these measures has been clinically proved to increase the chances 
of a patient's recovery, although all have been effective in animal experi- 
mentation. In certain cases, administration of adrenal cortocoids, such 
as hydrocortisone 100 to 300 mg. intravenously has seemed to potentiate 
the action of the pressor amine drugs, as has been demonstrated experi- 
mentally; generally, however, such therapy is ineffective. 

Other measures used in the treatment of shock include: (1) Rapid 
transfusion or plasma infusion (except in patients with elevated venous 
pressure) by the intravenous route (3 to 10 ml. per minute) or by the intra- 
arterial route (10 to 50 ml. per minute), (2) Hypothermia has been re- 
ported by Weil in shock of bacteremic infarction and by Vogelsang in shock 



Medical News Lietter, Vol. 32, No. 2 



of myocardial infarction. The latter author reported that three patients 
with severe hypotension promptly recovered after infusion of 250 ml. of iced 
(4° C. ) plasma. No confirmation of these results has been reported. (3) 
General care of the patient is important including adequate rest without 
excessive use of opiates which cause respiratory depression or antidiuretic 
effects, attention to bowels and skin, and oral intake of food. Any serious 
arrythmia should be corrected, but it should be noted that Prone styl may 
accentuate the hypotension. (Sampson, J. J. , Treatment of Shock in Myo- 
cardial Infarction: Dis. Chest, XXXin: 667-671, June 1958) 

5f: >J: 5(5 5}: :{! sjc 

Significance of the Serum Annylase Determination 

Since it has become well established that an elevated serum amylase 
level is the "sine qua non" of a valid diagnosis of acute pancreatitis, this 
laboratory procedure has been accepted as an essential part of the routine 
workup of the acute abdominal case. As data have been accumulated and 
analyzed, a considerable number of published reports have stressed that 
not only is the serum amylase elevated in many nonpancreatic conditions, 
but that a number of commonly employed drugs may significantly increase 
the amylytic activity of the serunn. As a result, the clinician finds it in- 
creasingly difficult to interpret an abnormal serunn amylase report and he 
is continually beset by the fear that too rigid adherence to "the elevated amy- 
lase = acute pancreatitis" concept may— in the acute abdominal case — lead 
to a serious diagnostic error. 

With the hope that a survey of a large series of serum amylase deter- 
minations might eliminate some existing confusion and shed light on the 
significance of the serum amylase determination, the authors reviewed the 
results of all such studies carried out at Georgetown University Hospital 
from 1949 through 1956. During this 7-year period, the spectrophotometric 
technique of Smith and Roe was ennployed and the procedure was in each case 
personally carried out or supervised by the same technician, A range of 40 
to 130 units was accepted as normal. Each determination was carefully 
correlated with the clinical record of the case including available surgical 
and postmortenj findings. The reviewed material consisted of 1840 deter- 
minations carried out in 977 cases as indicated by table. The serum amy- 
lase was abnormally high in 494 patients and in 379 (76%) of these, the eleva- 
tion was related to pancreatic disease. In 78 cases, an abnormally low 
amylase was found. 

This review of a large number of serum amylase determinations 
demonstrated that, although a rise occurs consistently in acute pancreatitis, 
a similar elevation occurs with sufficient frequency in other nonpancreatic 
disease to limit the diagnostic value of this laboratory aid. 



Medical News Letter, Vol. 32, No. 2 



The concept that an elevation of the serum amylkse is more impor- 
tantly related to impairment of free egress of the pancreatic juice into the 
duodenum than to pancreatic trauma is supported by clinical evidence. Pan- 
creatic calculi and sphincteritis are conditions in which obstruction to out- 
flow of pancreatic juice is obvious, while after surgical resection of the 
pancreas which is associated with considerable trauma, hyperamylasemia 
is not common. It is not possible to relate the factor of stasis of pancrea- 
tic juice to the elevation of the annylase in nnany nonpancreatic conditions, 
such as peritonitis and cholecystitis, although in some, a remote relation- 
ship, i. e. , increased intraluminal pressure in intestinal obstruction, is 
theoretically logical. 

Studies to be reported from the authors experimental laboratory con- 
firm the concept that obstruction of the pancreatic ducts and not necrosis of 
the pancreas is responsible for a rise in serum amylase. As a result of 
these investigations, evidence is accumulating that another enzyme, desoxy- 
ribonuclease (DNAase),is specifically related to cellular necrosis of the pan- 
creas — a fact that may have significant clinical value. 

Although the opposite view has been commonly held, the studies indi- 
cated that neither the height of the annylase elevation nor its duration served 
to distinguish acute pancreatitis from other acute abdominal conditions in 
which hyperamylasemia occurred. Furthermore, serum amylase values 
were not helpful in distinguishing between the edematous and the necrotic 
form of acute pancreatitis. In chronic pancreatitis, an elevated amylase 
was observed in less than half of the cases on admission, although an ele- 
vation was later identified during the period of hospitalization in additional 
cases with the result that in over two -thirds of cases a diagnostic elevation 
was noted. Hyperamylasemia is notably absent in cancer of the pancreas; 
in fact, a depression of the serum amylase level is more characteristic of 
this lesion. 

Direct operative attack on the pancreas provoked a rise of the serum 
annylase in less than one -fourth of the cases, suggesting that as long as 
free drainage of the pancreatic ductal systen:i is maintained, trauma in itself 
does not result in the elevation. 

Repeated determinations of the serum amylase are desirable during 
the course of acute and chronic pancreatitis, not only as an index of the 
activity of the inflammatory process, but as was observed in a number of 
cases in this series, a protracted elevation more often than not indicates 
the development of a peripancreatic collection or pseudocyst. 

In nonpancreatic diseases, an elevation of the serum amylase v^'as 
observed in a sufficiently large number of cases to dispel the belief that a 
specific relation exists between pancreatic disease and hyperamylasemia. 
Undoubtedly, the rise in some of these conditions, i.e., epidemic parotitis, 
penetrating duodenal ulcer, is at least partly the result of secondary pan- 
creatitis, but clearly, in many the pancreas was histologically normal. 



Medical News Letter, Vol. 32, No. 2 



The possible role of various drugs as an. explanation of serum amy- 
lase elevation in these nonpancreatic disorders was continually kept in 
mind in this review. In fact, studies concerning the influence of morphine, 
codeine, Demerol, Prostigmine, and intravenous alcohol on the nornnal 
serum amylase level are now being connpleted. While these investigations 
clearly confirmed the fact that some of these agents provoke an elevation 
of the annylase, cases in which the drug factor was the possible explana- 
tion of the abnornr^al serum amylase level were excluded from this study. 

The amylase level was elevated in every case of epidemic parotitis, 
in half of whom there was no associated abdominal pain. The fact that half 
the cases were complicated by mumps meningo-encephalitis is, in the 
authors' opinion, more indicative of the severity of the disease than of any 
specific relationship to the elevated amylase. It is interesting that in one 
of three cases of suppurative non-epidemiic and unilateral parotitis, a rise 
in serum amylase was found. 

Cholecystitis of both the acute and chronic type is attended by an 
abnornnally high serum amylase level in 17% of cases. An equally signi- 
ficant incidence of hyperannylasennia was observed in calculous disease 
of the comnnon duct, while in sphincteritis, the annylase was elevated in 
all of five cases. Whether the elevations of amylase associated with dis- 
ease of the extrahepatic biliary tree in cases having no demonstrable pan- 
creatic inflammation is due to the cholecystic or choledochal disease itself 
or the result of associated spasm of the sphincter of Oddi, is debatable. 

A noteworthy incidence of hyperanaylasemia was in association with 
duodenal ulcer (17%) and with gastrojejunal ulcer (66%). However, an 
elevated an:iylase rarely was observed in gastric ulcer. In almost one-half 
of the cases of posterior penetration of a duodenal ulcer, an elevation 
occurred, while in only two of 13 cases of free perforation was it observed. 
This latter incidence may be indicative of early institution of surgical clo- 
sure of the perforation, although the authors observed no relation between 
the interval of time from perforation to surgical closure and hyperamy- 
lasemia. The high incidence (41%) of elevated amylase following partial 
gastric resection is undoubtedly related in part to factors that impair free 
drainage of pancreatic juice. A sufficiently high occurrence of hyperamy- 
lasennia was encountered in intestinal obstruction (20%), mesenteric throm- 
bosis (33%), and peritonitis (69%) to establish the clinical fact that the 
demonstration of an elevated serum amylase in association with one of 
these conditions is not in itself an indication that pancreatitis coexists. 

In advanced renal disease and in a large unrelated group of miscel- 
laneous conditions, an occasional elevated serum amylase may occur. The 
finding of a distinctly subnornnal amylase level or the absence of annylytic 
activity of the serum is not unusual. In the presence of pancreatic disease, 
such a depressed amylase level is indicative of either carcinoma or ad- 
vanced chronic pancreatitis. Of the nonpancreatic conditions associated with 



Medical News Letter, Vol. 3Z, No. 2 



hypoainylasemia, cirrhosis and biliary tract disease are the most con- 
spicuous. {Abruzzo, J. Li. , et al. , Significance of the Serum Amylase 
Determination: Ann. Surg,, 147:921-927, June 1958) 

^ :^ =[c ;{!: s[: s[: 

Treatment of Infectious Mononucleosis 

A review of 1500 cases of infectious mononucleosis treated in the 
Department of Health and Preventive Medicine, Syracuse University, during 
the past ID years confirms the therapeutic failures of chemicals, but reveals 
a specific regimen of treatment that will produce consistently satisfactory 
results. This article presents the elements of that regimen. 

To establish a definite diagnosis in a disease as protean as infectious 
mononucleosis is not always easy. In many instances, its presence is sus- 
pected only after an iinsuccessful trial of antibiotics, particularly if the 
services of a clinical laboratory are not utilized. 

One should suspect that a patient with acute inflammation of the res- 
piratory tract has infectious mononucleosis if (a) swollen lymph nodes are 
palpable outside the drainage area of the inflamed tissue, (b) the spleen is 
enlarged, (c) there is a prolonged febrile course with systemic manifesta- 
tions, or (d) empiric antibiotic therapy fails to produce a response. Any 
bizarre group of symptoms and signs should arouse one's suspicion that 
the patient has mononucleosis. 

A positive diagnosis of infectious mononucleosis is made in the clinical 
and serological laboratory. However, laboratory findings are not entirely 
predictable. The finding of a lymphocytosis with an increase of atypical 
lymphocytes to 20% or more usually establishes the diagnosis. A lesser 
number of atypical lymphocytes is observed during the extremes of mono- 
nucleosis, but this is also seen in a great variety of diseases. The authors 
believe that an increase of atypical lymphocytes to 20% or more is patho- 
gnomonic of the mononucleosis syndronne and that a positive heterophil 
agglutination is only confirmatory. Heterophilic agglutination — like the 
presence of atypical lymphocytes — is not specific for mononucleosis and 
frequently additional absorptive procedures are necessary to give it sig- 
nificance. 

Not all patients who have infectious mononucleosis require treatnnent. 
The physician may discover the disease during a routine blood examination 
for a patient who is asymptonnatic or has only vague or slight symptoms. 
Many such patients recover promptly without treatment. However, infectious 
mononucleosis usually produces signs and symptoms disabling enough to 
require medical supervision; it is in this group that a specific therapeutic 
regimen will produce results that are uniformly good. 

The fundamental unit of therapy in infectious mononucleosis, there- 
fore, is rest, based on the need for conservation of energy and the shift 



Medical News Letter, Vol. 32, No. 2 



of energy to tissues concerned with defense and repair. The amount and 
type of rest are calibrated to individual needs. Activity must be restricted 
until the disease process has abated. The return of the white blood cell 
count to normal is the best indicator of this end point. 

Most patients with acute infectious mononucleosis have anorexia and 
painful deglutition. These symptoms can create problems in nutrition and, 
sometimes, relatively severe dehydration and electrolyte imbalance. Early 
in the acute phase, it is often necessary and wise to support the patient with 
intravenous sodium chloride, glucose, and water. This sinjple supportive 
measure alone often reduces the metabolic disturbance and places the supply 
and demand of energy in positive relation. I£ deglutition is painful, liquid 
or soft food is necessary. The diet should contain as many calories and as 
much protein as the patient can tolerate. 

Misinformation, fear of the unioiown, and the natural history of infec- 
tious mononucleosis lie heavily on the shoulders of the busy tense young 
patient. Education of the patient must begin as soon as the diagnosis is 
established. Relaxation and conservation of energy quickly follow under- 
standing in most instances. The physician should avoid setting arbitrary 
limits on the period of disability and he should not initiate acceptance of the 
treatment program through fear of consequencss. Recognition of the patient's 
environmental stresses enable him to assist in minimizing their impact. As 
the acute phase of illness subsides, the supervising physician should start a 
positive program to return the patient to activity, beginning by planning the 
program with the patient and then gradually putting the plan into action. 
Patience and understanding are necessary ingredients of the program and it 
should emphasize positive activity (things that can be done) rather than nega- 
tive activity (those that cannot). 

Medical agents used in treatment of infectious mononucleosis during 
the past 20 years are voluminous. For the most part, they comprise four 
groups and are listed in a table: symptomatic agents, substances that in- 
fluence (or theoretically influence) human metabolism, antibacterial agents, 
and steroid hormones. Review of the practical problems involved in mono- 
nucleosis explains the rational application of some of the substances in each 
group. In the present series, only the drugs in the first group — symiptomatic 
agents — were used in all cases. 

Several surgical complications are associated with mononucleosis. 
At times they are serious. Heading the list is a ruptured spleen. The frame- 
work of the spleen often becomes disorganized and friable in the presence of 
infectious mononucleosis. Therapy with reference to this organ should be 
prophylactic. Repeated attempts to palpate the spleen should be avoided. 
Spontaneous rupture is possible, and abdominal pain, nausea, vomiting, and 
shock should arouse one's suspicion that it has occurred. Prompt surgical 
intervention in either traumatic or spontaneous rupture of the spleen can 
be life saving. 



Medical News Letter, Vol, 32, No. 2 



Enlarged lymph glands in the abdominal area may simulate many 
surgical conditions. The clinical signs and symptoms may be classic of 
acute appendicitis. In the early stages of mononucleosis, the absence of 
a typical blood count may further complicate the picture. Even more dis- 
tressing is an almost pathognomonic picture of acute appendicitis with a 
typical mononucleosis blood pattern. There is no clear-cut way of sep- 
arating these two problems and yet separation is mandatory. The authors 
found that hourly clinical observation is the best aid and will lead to differ- 
entiation in about 75%. Unfortunately, 25% defy classification. In the latter 
cases, medical intelligence will dictate abdominal surgery. 

Therapy designed to lessen the impact of the destructive and disorgan- 
izing phase of the inflammatory reactions involving the nervous system is 
experimental. Clinical improvement in specific cases of mononucleosis 
complicated by neuritis and paralysis reportedly has followed administra- 
tion of Z, 3-dimercaptopropanol (BALi). Because of the relatively low inci- 
dence of this type of pathologic process in mononucleosis, statistically 
significant results of any therapy are probably unattainable. 

Rapid reversal of paralysis of the seventh cranial nerve not assoc- 
iated with mononucleosis has been observed in several clinics following 
the administration of steroid hormones. This experience combined with 
the well-established resolution of the pathologic process of mononucleosis 
subsequent to steroid therapy would suggest that — at least experimentally — 
steroids should be administered to patients with mononucleosis who have 
involvement of nerve tissue. (Cronk, G. A. , Naumann, D. E. , Treatment 
of Infectious Mononucleosis - A Review of 1500 Cases: Postgrad. Med., 
23 : 605-611, June 1958) 

* >;5 * * * * 
Tuberculosis - A Disease of Old Age 

Since the beginning of the century and especially since the most recent 
advances in the battle against tuberculosis through effective chemotherapy, 
the age distribution of the disease haL^ changed radically in those parts of 
the world where a concerted attack on tuberculosis has been possible. The 
first great change was accomplished through effective sanitation of the milk 
supply which resulted in practically complete control of bovine tuberculous 
infection in a few countries, notably the United States; the secondary mani- 
festations of bovine infections — particularly tuberculous osteomyelitis — 
have since become comparatively rare. 

This achievement in combination with the enlightened concept that 
exposure to the human bacillus in home life is the main source of clinical 
pulmonary tuberculosis resulted in a decline of the mortality among children 
to very low values even before the era of chemotherapy. American statistics 



10 Medical News Letter, Vol. 32, No. Z 



show a remarkable decrease from about 200 deaths in children, per 100,000 
population between 1900 and 1954. During the past decade it has almost 
reached the zero point. 

The decline of the mortality curve for the total population during the 
past 50 years which has proceeded at an even pace with elevations only during 
the two world wars shows some of the factors which are at work in the tuber- 
culosis problenn when the data are analyzed as to sex, race, and age. In the 
United States, the picture is greatly influenced by the prevalence of the ex- 
udative and progressive forms of pulmonary tuberculosis among the non- 
white and immigrant elements of the population, chiefly the Negroes, the 
Puerto Ricans, and the refugees from war-torn countries, and to some 
extent also by the American Indian, Undoubtedly, the decline of the mortal- 
ity curve as it appears in published statistics conveys an over optimistic 
impression if it is interpreted in terms of "cured" or "healed" tuberculosis. 
It is impossible to measure over a period of only a few decades the true 
killing effect of a chronic disease if that disease in individual patients can 
outlast the period of recording. It is known that the lower mortality is not 
the mere result of the decrease in the number of new active cases. There- 
fore, it must be assumed that, especially during the past 10 years of chemo- 
therapy, the swiftness of the decline of the mortality — at least in part — is 
not so much due to the number of persons cured of tuberculosis as to the 
increasing chronicity of the disease which has shifted its weight into an 
older age group of the population. This change has become one of the most 
burning problems in tuberculosis care. 

In the past, the cirrhotic, fibroid, and fibrocaseous forms of pulmon- 
ary tuberculosis have been a rather uniform finding in elderly patients, who 
usually had been tuberculous for many years, although with new bronchogenic 
exacerbations. In recent years, it has been a surprising and somewhat 
puzzling experience to find many fresh exudative involvements in patients 
where the absence of tuberculosis had been established when they were al- 
ready in the old age group. The clinical-pathological picture of tuberculosis 
in the aged, therefore, differs less from that seen in young people than one 
should expect. There has been speculation that this type of senile disease 
might be due to the fact that first infection with the tubercle bacillus occurs 
increasingly at a higher age than used to be the case and that a shorter 
period is available during which subsequently an adequate acquired immune 
resistance can develop. However, this consideration can hardly apply to 
the present-day senile patient whose childhood still fell into the period when 
primary infection occurred in the great majority of children. The likeliest 
explanation is that in previous generations, when roentgenologic exannina- 
tion was either not available or not applied widely, when the public as well 
as the medical mind associated tuberculosis essentially with the young, the 
disease was not expected and consequently not looked for in old persons. 
.Its symptoms — if any — and eventually even death in many cases were attri- 
buted to nontuberculous causes. 



Medical News Letter, Vol. 32, No. 2 H 



The question of the infectiousness of tuberculosis in some ways has 
become more complicated through modern chemotherapy rather than sim- 
plified. For practical considerations, the authors distinguish three main 
groups of sputum findings: in the first group, the sputum remains abund- 
antly positive both on direct nnicroscopic examination and on culture even 
under vigorous chemotherapy; in the second group, the production of bacilli 
is diminished to only occasional and scant positive results on culture; in the 
third group, the sputum is completely negative on all tests by both direct 
microscopic examination and culture. The patients belonging to the first 
group cannot be pernnitted to return home to live with children and young 
adults even under the most favorable living conditions. Those in the second 
group are considered by many authors as practically noninfectious and re- 
ports have been published indicating that they do not spread active disease 
and do not even lead to conversion of the response to tuberculin fronn nega- 
tive to positive among persons living in their environment. 

One may not believe in the danger of occasional exposure to infec- 
tion as a major factor in the distribution of tuberculosis, but the continuous 
contact in intimate home life has long proved itself to be the essential cause 
of clinical disease. When the findings from routine roentgenologic exam- 
inations of the general population were compared with those in persons 
knov^n to have lived in close contact with tuberculous individuals, it was 
found that the incidence of clinically important tuberculosis was three times 
as high in the latter group as among even the socially underprivileged of the 
general population. Therefore, in spite of favorable reports to the contrary, 
extreme caution is indicated lest grandparents be sent home to infect their 
grandchildren where in the past parents have often carelessly been per- 
mitted to infect their children. This thought should apply even to the third 
group of patients with negative sputum findings of seeming reliability. 

Surgical resection of the most dangerously involved parts of the lung 
is now employed with impunity even in elderly patients, but as a group, 
they are the least suitable for this form of therapy because of the high inci- 
dence of complicating factors which impair respiratory capacity and cardiac 
fxmction. 

The social, economic, and emotional problems of old age tuberculosis 
even over-shadow the medical difficulties. The senile patient is lonely and 
wretched; often he has neither fanaily nor friends; if he is widowed, his chil- 
dren — themselves beset by poverty — may not be able and at times are not 
willing to add to their burden by the small and larger ministrations by which 
they could show their affection and devotion. The old patient is frightened 
and helpless and his reliance on social and welfare agencies is complete. 

Since chemotherapy has come to the fore, the idea of home care for 
the tuberculous has received widespread attention. Unquestionably, the 
period of hospitalization can now be shortened and treatment continued at 
home, but home therapy without an initial stay in a hospital or sanatorium 
cannot be recommended. It is bound to fail in many aspects of diagnosis 



12 Medical News Letter, Vol. 32, No. 2 



and therapy and deprives the patient of the indispensable education in the 
meaning and demands of his disease by having contact with other patients 
and being in the specifically created atmosphere of a tuberculosis hospital. 
When the time for discharge and home care approaches, the patient's 
social and economic situation often makes it hard or impossible for phys- 
icians and social workers to adjust the humane interpretation of the word 
"home" to what in reality is awaiting the patient, A flat on the top floor of 
a cheap walkup rooming house is not home, nor does a room for a whole 
family in slum quarters deserve that name. In brief, an address cannot be 
assumed to be a home before a thorough investigation has been made which 
appraises the home situation on the basis of high standards. Supervised 
rest and quiet, cleanliness, and comfort are still the mainstay in the treat- 
ment of tuberculosis. As yet proof has not been offered that the old methods 
can be replaced simply by the free provision of antibiotics by the community, 
even assuming that the drugs are taken as they were prescribed. 

The closing of tuberculosis hospitals and sanatoria in reliance on 
modern chemotherapy is premature. They should serve as the desperately 
needed homes for homeless aged tuberculous patients where they can enjoy 
a secure dignified and happy existence. Institutional care for tuberculosis 
in the sense of this altered interpretation of the term will develop more 
and more into a crying need as the disease increasingly becomes a geria- 
tric problem. (Bloch, R. G. , Tuberculosis - A Disease of Old Age: Arch. 
Int. Med., 101: 1057-1064, June 1958) 

Localized Pulmonary Emphysema of Infancy 

Localized pulmonary ennphysema of infancy is now being recognized 
with increasing frequency. It presents characteristically as hypertrophic 
pulmonary emphysema localized to one lobe of the lung with infection — if 
present — having no relationship to the emphysematous process. An emer- 
gency situation may arise from the rapidly progressing lobar distention 
that may terminate fatally without prompt and proper management. Reports 
of successful treatment by resection of the emphysematous lobe have made 
this a condition of practical concern to both pediatricians and surgeons. 

A variety of names have been given to the condition including infan- 
tile lobar emphysema, tension emphysema in infants, progressive infantile 
emphysema, localized hypertrophic emphysema, lobar emphysema in in- 
fants and children, lobar obstructive emphysema in infancy, and congenital 
lobar emphysema. In many cases, the etiology remains obscure, whereas 
in others it has been attributed to maldevelopment of the bronchial carti- 
lages or redundant folds of bronchial mucosa. It has been found in assoc- 
iation with defects of the mediastinum. In several instances, it has been 



Medical News Letter, Vol. 32, No. 2 13 



associated with bronchial compression by a ductus arteriosus or by pres- 
sure from an abnormal vessel. Despite uncertainties concerning its etio- 
logy and pathogenesis, the condition does present findings sufficiently 
characteristic to warrant its consideration as a distinct entity of infancy. 
It should not be confused with conditions presenting as areas of localized 
pulmonary emphysema secondary to partial bronchial obstruction associa- 
ted with infection, atelectasis, tumors, strictures, or aspirated n:iaterial. 
Localized emphysema of infancy also needs to be differentiated fronn lung 
cysts, atelectasis with compensatory emphysema, pulmonary agenesis, 
pneumatocele, diaphragmatic hernia, and pneumothorax. 

Nothing of significance was noted in the prenatal or birth history of 
the 40 cases reviewed. Premature births occurred in 4% of the infants 
with localized pulmonary emphysema. This figure is not remarkable be- 
cause it falls within the normal incidence of prematurity seen in an average 
large obstetrical service. Ehrenhaft has suggested that vigorous resusci- 
tation of the newborn miight be a factor in the genesis of this condition. Of 
the 40 cases reviewed by the authors, 17 had no comment concerning resus- 
citation. In the remaining cases, 22% were definitely stated to have under- 
gone resuscitative measures. Although this figure is higher than one might 
normally expect, it is difficult to evaluate because there were no detailed 
descriptions as to the nature and extent of the measures employed. 

Sex incidence was significant in that the ratio of male to female in- 
fants was 2 to 1. In the present group there were '3 males and 1 fennale. 
In the literature, there were 21 male infants, 11 females, and 4 whose 
sex was not stated. 

The predominant symptoms were those associated with progressive 
respiratory embarrassment. Dyspnea was mentioned in 33 of the 40 cases. 
Twenty-five infants were noted to have had cyanosis which was often inter- 
mittent. In 14 cases, a wheeze had been heard. Feeding difficulty and 
cough were described in 9 end 8 cases, respectively. Only 6 infants had 
respiratory infections; these were generally mild and appeared to have had 
no direct relationship to the emphysematous process. The average time 
of onset of symptoms was at the age of 25 days. In 17 infants, synnptoms 
began during the first week of life. In the remaining ones, respiratory 
difficulty became apparent by 2 months of age except for 3 in whom the 
symptoms began between the second and sixth months. 

The usual physical findings were those of respiratory distress; the 
severity was related directly to the degree of emphysematous lobar disten- 
tion. The physical sign noted most frequently was mediastinal shift. The 
location of the apical heartbeat was found to be the most reliable method 
for determining the degree of mediastinal deviation in infants. Inspiratory 
retraction, decreased breath sounds, and hyper-resonance over the in- 
volved side of the chest were mentioned in slightly less than half of the 40 
cases. Cyanosis and dyspnea were stated to be present in approximately 



14 * Medical News Letter, Vol. 32, No. 2 



one -third of the cases. In many others, continuous oxygen administration 
may have masked these signs. Interestingly enough, only 8 infants were 
noted to have wheeze during hospital admission. 

In most instances a detailed history and thorough physical examina- 
tion with a frontal and lateral chest x-ray will permit a correct diagnosis 
of localized pulmonary emphysema. Needle aspiration or insertion of an 
intercostal tube has been performed to relieve the intrathoracic air tension. 
The authors believe that, unless one is certain of a diagnosis of pneumo- 
thorax, these procedures are fraught with considerable danger. In the 
cases reviewed in ^which localized pulmonary emphysema was treated by 
needle aspiration or insertion of an intercostal tube, the results were uni- 
formly bad leading to rapid deterioration and often death. 

Progressive localized pulmonary emphysenna is best treated by ex- 
cisional surge ry^ Any patient suspected of having this disease with uninn- 
proved or progressive respiratory distress should have thoracotomy and 
excision of the emphysematous lobe. Occasionally, thoracotomy may be 
necessary to establish the correct diagnosis. Thirty-five of the 40 infants 
had definitive pulmonary resection. The age at the time of surgery varied 
from 6 weeks to 4 years with nnore than three -fourths of the patients under 
6 months of age. The average age at the time of operation was 6. 3 months. 
In more than half of the cases, the operation would seem to have been elec- 
tive in nature and to have been performed because of persistent or slowly 
^A» progressive symptoms. Ten other infants were operated upon as urgent 
respiratory problems meaning that the operation was necessary within 
several days after admission to the hospital due to progressive respiratory 
distress. Three cases were operated upon as emergency procedures 
within several hours after hospital admission because of their critical 
respiratory status. (Jewett, T. C. Jr. , Adler, R, H. , Localized Pulmon- 
ary Emphysema of Infancy: Surgery, 43: 9Z6-932, June 1958) 

1* ^ ^r ^T" "T* T^ 

Acetazolamide (Diamox) Therapy 
in Chronic Glaucoma 

Since 1954, when acetazolamide (Diamox) became available as an 
additional therapeutic agent for the management of glaucoma, several re- 
ports dealing with long-term acetazolamide therapy in chronic glaucoma 
have been published. A variety of hypotheses have been advanced concern- 
ing the mode of action of this drug. At the present time, all that can be said 
with certainty is that acetazolamide is a specific carbonic anhydrase inhibi- 
tor, that it lowers intraocular pressure of human and animal eyes, and that 
it does so by a partial inhibition of aqueous humor formation. The nnechan- 
ism of action of this drug as well as its exact locus of action still remains 
to be demonstrated. Because carbonic anhydrase is known to be present 



^' 



Medical News Letter, Vol. 32, No. Z 15 



in lens epithelium, ciliary body, and retina, it became of immediate int- 
erest to study two main problems: (a) Does long-term administration of 
acetazolamide interfere with the metabolic processes of ocular tissues? 
(b) Will the prolonged administration of acetazolamide irreversibly sup- 
press the process of aqueous formation, i.e., produce a "biochemical 
c yclodiathe rm y " ? 

This report deals with two general aspects: (1) the effect of 2 or 3 
years of continuous acetazolamide and miotic therapy on the aqueous dy- 
namics of glaucomatous eyes, and (2) a critical evaluation of the clinical 
status of patients maintained on long-term acetazolamide and miotic ther- 
apy. Of 24 patients with chronic open-angle glaucoma uncontrolled by max- 
imal medical therapy, 21 (87%) had controlled intraocular pressures over 
a 3-year period of acetazolamide (Diamox) and miotic therapy. The average 
reduction in pressure was 12 mm. Hg. and the lowered pressure was pri- 
marily due to a reduction of aqueous flow (average 60%) as measured by 
tonography. 

The over all percentage of failures in this series of clinic patients 
was 13 to 21%; 6 of 28 eyes (21%) revealed progressive visual field loss in 
spite of controlled intraocular pressure. 

The exact site and mode of action of acetazolamide still remains to be 
established, but there is no evidence that long-term acetazolamide therapy 
irreversibly suppresses the formation of aqueous humor. Following discon- 
tinuation of long-term acetazolamide therapy, the intraocular pressure rose 
to essentially pretherapy levels. The longest follow-up of continuous aceta- 
zolamide therapy in this series was 38 months. 

Acetazolamide appears to be a relatively safe drug. Mild parathesias 
occurred in at least 50% of patients. Moderate or severe side effects oc- 
curred, but were rare in the authors' experience. There were no signifi- 
cant ocular complications. Vision and visual fields vv/ere maintained in 
many eyes where the prognosis would have been poor without the addition 
of acetazolamide therapy. 

Until longer follow-up studies are available, it is advisable to defer 
the use of long-term acetazolamide therapy until the various local thera- 
peutic agents have proven inadequate. It should than be used as an adjunct to 
other therapeutic measures and not as a substitute. 

That this study deals solely with chronic simple glaucoma cannot be 
overemphasized. Except during the immediate preoperative period, aceta- 
zolamide therapy has no place in the management of acute congestive or 
closed-angle glaucoma. (deCarvalho, C. A. , Lawrence, C. , Stone, H. H. , 
Acetazolamide (Diamox) Therapy in Chronic Glaucoma - A Three-Year 
Follow Up Study: Arch. Ophth, , ^: 840-848, June 1958) 

sic >[; ;Jc i[t ;^ >[; 



16 Medical News Letter, Vol, 32, No. 2 



Surgery of Portal Cirrhosis of the Liver 

The surgery of portal cirrhosis of the liver consists in treatment of 
the secondary effects of this disease rather than a direct surgical attack 
on the primary condition in the liver. This is a discouraging aspect be- 
cause surgery does not improve the over all picture of the primary cirrho- 
tic disorder apart from protecting the liver from repeated insults due to 
recurring esophageal hemorrhages and the nutritional disturbance assoc- 
iated with ascites. Nevertheless, after 13 years of experience with this 
type of surgery, there can be no question that life has been prolonged in 
many instances and that the majority of patients have been rehabilitated 
with a marked reduction in morbidity. 

Generally, it is agreed that the chief indication for surgical therapy 
in portal cirrhosis of the liver is prevention of hemorrhage from esopha- 
geal varices — a common source of upper gastrointestinal bleeding and 
frequently the cause of death in the untreated or medically treated patient. 
The seriousness of esophageal hemorrhage in patients with cirrhosis of the 
liver has been recognized for many years. Patek, Nachlas, and ShuU have 
each reported fronn three different medical centers that when medical meas- 
ures alone were used, the mortality rate in patients with cirrhosis of the 
liver after the first hemorrhage fronn esophageal varices varied from 30 
to 50% during the first year. The major causes of death were (1) exsan- 
guinating hemorrhage, and (2) liver failure, in many cases precipitated by 
esophageal bleeding. 

The second indication for surgical therapy in this group of patients 
is relief of ascites uncontrollable by medical nneasures. Unfortunately, 
it is only the occasional patient with marked ascites vvho can be helped by 
surgical measures. Remarkable improvement can be obtained in many of 
these patients by utilization of medical measures, including an adequate diet, 
low sodium intake, use of diuretics and, if necessary, intravenous adminis- 
tration of hunnan seruin albumin. Many patients with bleeding esophageal 
varices who also have slight to moderate ascites are relieved of their ascites 
by the construction of some type of anastomosis between the portal venous 
system and the systemic venous systena. Results in a few other patients 
with uncontrollable ascites and without esophageal varices have been even 
more spectacular. This is a select group of patients with ascites which 
does not respond to medical measures despite a relatively nornnal level of 
serunn albunnin, above 3 gm, %. 

Any discussion of the surgery of cirrhosis of the liver would be in- 
complete without considering the emergency treatment of a patient with exsan- 
guinating hemorrhage from esophageal varices because of the high mortality- 
rate in these patients when treated by conservative measures. Statistics col- 
lected at the Massachusetts General Hospital in the 5-year period from 1946 
to 1950 inclusive reveal an appalling mortality rate in cirrhotic patients with 
acute, severe esophageal bleeding. 



Medical News Letter, Vol. 32, No. 2 17 



Patients with severe exsanguinating esophageal hemorrhage have 
been treated as surgical emergencies. The following procedure in these 
cases has been carried out: First, cardioesophageal tamponage is insti- 
tuted by use of an intragastric balloon. By this means, it is usually pos- 
sible to stop bleeding from esophageal varices in a few minutes by applying 
a 2 -pound weight to the end of the balloon tube after the balloon has been 
inserted into the stomach and inflated. It is recon:)n:iended that when this 
has been accomplished, the patient's blood volume be restored by repeated 
blood transfusion, the operating room be prepared, and in a matter of a 
few hours, the patient — unless in impending liver failure — be taken to the 
operating room and the esophageal varices sutured through a transthoracic 
transesophageal exposure. It is recomimended that the operative procedure 
be carried out in this manner as soon as possible rather than waiting to see 
if bleeding will recommence when the tube is removed in 24 or 48 hours, 
which not infrequently occurs; when it does, the patient is usually in a much 
worse condition to withstand surgery of this magnitude. 

It is recommended, therefore, that if cardioesophageal tamponage with 
a balloon tube is necessary to save a patient from exsanguinating hemorrhage, 
an emergency operation to suture the esophageal varices should be per- 
formed without delay. Fortunately, not all patients with bleeding esophageal 
varices hemorrhage in this manner so that it is not always necessary to 
carry out tanmponage or emergency surgery. The decision as to which 
patients should have their esophageal varices sutured should be made by 
selecting only those in whom it has been necessary to institute balloon 
tamponage to control the esophageal hemorrhage. 

This is not a definitive procedure and for that reason should be con- 
sidered only the first stage of a two- stage operative program. Fortunately, 
it controls the bleeding in the majority of patients for a period of 6 weeks to 
2 months, thereby permitting more thorough preparation of the patient for 
the larger surgical procedure of constructing some type of portacaval shunt. 

The tnost effective definitive treatment of bleeding esophageal varices 
secondary to cirrhosis of the liver that has been developed is the construc- 
tion of either a splenorenal or a direct portacaval anastomosis. The results 
to date with this method of surgical therapy have been extremiely encourag- 
ing. The life of the cirrhotic patients has been prolonged and the incidence 
of bleeding greatly reduced. In a few patients with uncontrollable ascites, 
despite their ability to maintain a normal serunn albumin level, the construc- 
tion of a splenorenal shunt has produced spectacular results in the relief of 

ascites. 

It should be emphasized that the success of this type of surgery in 
many of these critically ill patients demands the closest cooperation of the 
internist, the surgeon, and the anesthesiologist. {Liinton, R. R. , The Surgery 
of Portal Cirrhosis of the Liver: Am. J. Med., XXIV : 941-947, June 1958) 

^ s); ^ jjc 5!< sic 



18 Medical News Letter, Vol. 32, No, 2 



Surgical Parotitis 

Surgical parotitis is an acute inflammation of the parotid gland, either 
unilateral or bilateral, occurring most frequently after surgical procedures. 
Although it is an infrequent and linexpected complication, it is quite alarm- 
ing when it does occur. In the past, it has carried a high mortality rate 
and has been regarded in the literature as a grave prognostic sign. 

It has long been known that patients developing parotitis were usually 
seriously ill, in poor general condition, dehydrated, undernourished, and 
with poor oral hygiene. A dry mouth and a decreased salivary secretion 
seems to be the principal precursor to the onset of the disease. The high- 
est incidence has occurred after abdominal or genitourinary tract surgery. 

The infection is almost always caused by the Staphylococcus aureus 
organism. At the turn of the century, experimental laboratory work was 
divided in theory as to whether the infection was a hematogenous invasion 
of the gland or an ascending infection from the mouth by way of Stensen's 
duct. The latter theory is now more generally accepted. Frequently, the 
prolonged trauma of pressure on the gland by the anesthetist has been sug- 
gested as contributory to the onset of the infection. 

The diagnosis is easily made by finding an enlarged tender gland. The 
onset is usually 4 to 6 days after operation and by far the majority of cases 
appear within the first Z weeks following surgery. Occasionally, the first 
symptom is pain in the temporomandibular joint, but nnore frequently, 
there is localized pain and swelling in the gland. A febrile response occurs 
within Z4 hours with temperatures of 102 and 103° F. along with an acute 
elevation in the leukocyte count. Mortality rates have always been high, 
varying from 30 to 60% in most series reported. Despite these high figures, 
parotitis has rarely been considered the primary cause of death; rather, it 
has been looked upon as indicative of a poor prognosis in those already 
critically ill. 

Early treatment was ainned at stimulating salivary secretion by use 
of mouth washes, chewing gum, and hard lemon candies, along with warm 
or cold compresses. Determination of abscess formation by fluctuation is 
difficult because the parotid gland is covered by an extremely dense and 
unyielding fascia. Incision and drainage, therefore, have often been delayed. 
The resulting scar of the face and fear of injury to the facial nerve have been 
other reasons given for the delay of surgery. 

All of these patients but one were acutely ill after extensive intra- 
abdominal surgery and all were on antibiotic therapy when the parotitis 
developed. Four cases in which organisms could be cultured were positive 
for antibiotic-resistant S. aureus. All patients were treated with x-ray as 
an emergency procedure within the first 12 hours after the onset of symptoms 
and immediately upon making the diagnosis. The dosage of x-ray was 75 r 
to gland tissue daily. One patient responded to x-ray therapy only within 48 hours. 



Medical News Letter, Vol. 32, No. 2 19 



Within 48 to 72 hours, when it appeared clinically that the swelling 
and pain were progressing despite x-ray therapy, six patients were sub- 
jected to decompression in the operating room under local 0. 5% procaine 
anesthesia. A hockey-stick incision was started just anterior to the ear 
and extended 1 inch to a point just below the angle of the mandible and then 
forward below and parallel to the nnandible I to 1-1/2 inches farther. The 
parotid capsule was then split a distance of 1 to 2 inches without incising 
the gland itself. The authors were impressed by the marked thickening of 
the parotid capsule which measured 2 to 3 mm, in each instance. No pus 
was obtained by needle aspiration in any case. The wound was loosely 
packed with iodoform gauze, and warm connpresses were applied for 2 to 
3 days. 

Relief from pain was almost immediate in each case and marked re- 
duction of swelling was noticed with the first 3 to 4 hours. Recovery oc- 
curred in each case during the next 3 to 4 days. There was no evidence of 
abscess formation in any case. Postoperative scarring was minimal. No 
x-ray therapy was given after the surgical procedure. One death occurred 
in this series; that was on the 18th postoperative day of resistant Staphy- 
lococcus infection and septicemia. The parotitis had subsided in the mean- 
tims. (Gilchrist, R, K. , McAndrew, J. R. , Surgical Parotitis: Arch. Surg., 
76 : 863-865, June 1958) 

* 5l< * * * >!: 

Practical Aspects of a Hearing 
Conservation Program 



The health problems created by intense noise are becoming increas- 
ingly more acute. In addition to the danger of blast and instantaneous ex- 
cessive noise, continuous and intermittent exposure to loud noises over 
a period of time may result in hearing loss. This loss may be temporary 
and recovery may ensue or it may be permanent because of injury of the 
inner ear. Susceptibility to hearing loss due to noise varies greatly among 
different individuals; some persons can tolerate much more than others 
v^ithout inner ear damage. Loss usually occurs first in the higher -pitched 
tones above 4000 cps. Those in whom the loss is centered in this high 
range suffer quite extensive impairment before the speech range (300 to 
3000 cps) is appreciably affected, and long before they become aware of 
a change in auditory acuity. 

There is no clear-cut lower level established above which noise is 
definitely hazardous to health. Factors, such as frequency, nature of the 
noise (intermittent or continuous), and the length of exposure greatly in- 
fluence the level of pernnissible exposure. A hearing conservation program 
should be undertaken when the noise level exceeds 85 to 90 db. as measured 



20 Medical News Letter, Vol. 32, No. 2 



on the "B" weighting network on sound-level meter; this coincides in gen- 
eral with conditions that exist when it is difficult to hear a loud spoken 
voice at a distance of one foot. 

Noise measurements and analyses are essential in order to evaluate 
the extent and nature of the hazard, to determine the need for establishing 
preventive measures, and to evaluate the effectiveness of a hearing con- 
servation program. 

To accomplish ideal control of increased noise output, various ap- 
proaches are used, examples of which are attenuation of noise at its source 
by engineering design of machines, substitution of a less noisy operation for 
a noisy one, isolation to a remote area, acoustical treatment of rooms, resil- 
ient mountings, and surrounding the noise source with an enclosure. 

Audiograms should be taken in sound treated rooms, or the equivalent, 
with an ambient noise level no greater than approximately 45 db. The recom- 
mended test frequencies are : 500, 1000, 2000, 3000, 4000, and 6000 cps. 
Hearing acuity is best evaluated on an individual basis. Audiograms should 
be taken as a part of all preplacement of preemployment physical examina- 
tions and routine periodic or recheck audiograms should be made on all 
personnel working in high-intensity noise areas. 

Three general personal protective methods of occluding the ear with 
devices that attenuate airborne noise are: Insert types — plugs inserted into 
the ear canal, cushion or doughnut types — objects which cover at least the 
entrance to the ear canal and often the entire outer ear, and helmet types — 
fitted coverings for the major area of the head. In same cases, adequate 
protection may require the combination of these techniques. The occupation- 
al medical doctor and his staff should be responsible for the distribution and 
proper fitting of protective ear devices. Every effort should be made to 
assist personnel in their understanding and acceptance of ear protection. 
(Shone, L. B. , Captain MC USN, Practical Aspects of a Hearing Conser- 
vation Program: Arch. Indust. Health, 17: 610-613, June 1958) (Occ Med- 
DispDiv, BuMed) 

:^ ^ ^ ^ ^ :fli 

Policy 

The U. S. Navy Medical News Letter, is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
nor are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 



Medical News Letter, Vol. 32, No. 2 21 



From the Note Book 

1. Rear Admiral B. E. Bradley MC USN represented the Navy Medical 
Department as military member at the House of Delegates Meeting of the 
American Medical Association held in San Francisco, Calif. , June 23-26, 
1958. (TIO, BuMed) 

2. Rear Admiral E. C. Kenney MC USN represented the Surgeon General 
at the Twelfth Naval District Symposium on Medical Problems of Modern 
Warfare and Civil Disaster in San Francisco, Calif. , on June 19 and 20, 
1958; and at the Sixth Annual National Medical Civil Defense Conference 
on June 21, 1958. 

3. Captain W. M. Silliphant MC USN, Director of the Armed Forces Insti- 
tute of Pathology, participated in the Joint Meeting of the Canadian Assoc- 
iation of Pathologists and the Atlantic Provinces Association of Pathologists 
held in Halifax, Nova Scotia, 20-21 June 1958. (A. F. I. P. ) 

4. National Bureau of Standards Handbook 66, was prepared under American 
Standards Association procedures. As industrial use of radioactive materials, 
x-rays, and particle accelerators increases, it is essential that adequate 
precautions be taken to protect the user and the public against excessive 
exposure to radiation. This Handbook has been composed to serve as a 
guide toward safe design, nnanufacture, installation, use, maintenance, 

and disposal of beta-ray sealed sources for industrial applications. (N. B. S. ) 

5. "For the Nation's Health" is a l6 mm. filmograph, color, sound, 15 
minutes. 1957. This Public Health Service orientation film presents a 
panoramic view of the activities of the principal health agency of the Fed- 
eral Government. Combining photographs and motion picture film, it shows 
the growth of the Public Health Service from its inception in 1798, with lina- 
ited care of sick and stranded merchant seamen, to its farflung programs 
today in hospital and medical care, in medical and biological research, and 
in public health. (P. H.S. , H. E. vV.) 

6. More than 4500 Navy personnel have participated in the Navy's two 
Antarctic operations. Deep Freeze I and II. Through their efforts, an area 
the size of the United States and Western Europe combined has been explored, 
much of it never before seen by man. (Research Reviews, June 1958) 

7. Resection of entire lobes of the liver, while not a new procedure, was 
rarely accomplished until the past 15 years. Right hepatic lobectomy is 
still so unusual that only a score of patients have been reported as sur- 
viving the procedure. This article reports 3 additional patients with benign 



22 Medical News L tter. Vol. 32, No. 2 



conditions requiring hepatic lobectomy, 2 left and 1 right, with excellent 
results. (Ann. Surg., June 1958; R, C. Clay, M. D. , G.G, Finney, M. D. ) 

8. The authors report their experience with 12 patients with tricuspid sten- 
osis. Five cases are presented in detail to emphasize the variable mani- 
festations of the lesion. The clinical data of the 12 patients are discussed 
in relation to the hemodynamic data and with particular reference to the 
symptoms and signs which are considered of aid in the diagnosis, (Am. J. 
Med., Jiine 1958; T. Killip m, M. D. , D. S. Lukas, M, D.) 

9. A study was made of 29 patients proved to have sarcoidosis in a 29-nnonth 
period. The unusually high incidence rate found may reflect partially the in- 
clusion of a number of asymptomatic patients and suggests that the disease 
is more prevalent than is commonly recognized, A predilection for sarcoi- 
dosis apparently exists in both white and Negro patients who have lived in 
the southeastern part of the U. S. The incidence rate for Negroes in this 
series was 12 times that of white persons, {Arch, Int. Med., June 1958; 
Major R.H. Ferguson (MC) and Captain J. Paris (MC) USAF) 

10. An operation for the correction of developmental deformities of the 
anterior chest wall is described in detail. The procedure involves an ex- 
tensive dissection and mobilization of the sternum and the adjacent anterior 
chest wall and no external prosthesis or splint is employed. (J. Thoracic 
Surg., June 1958; R.A. Daniel Jr. , M. D. ) 

11. Cor pulnnonale is defined as right ventricular hypertrophy due to a 
disordered pulmonary circulation regardless of the cause. Pulmonary 
heart disease, ennphysema heart, and pulmonary hypertensive heart disease 
are types of cor pulmonale. Each refers to right ventricular hypertrophy 
of more or less specific origin. Brief notes on diagnosis and treatment are 
presented. (Dis. Chest, Jime 1958;!. C. Brill, M. D. ) 

12. In this study, the authors used a simplified classification of peripheral 
arterial occlusive disease and discussed ulceration, claudication, age, and 
diabetes as they affected prognosis. (Arch. Surg., June 1958; H.J. Robb, 
M. D, , et al) 

13. This report represents a review of the surgical experience obtained 
from 403 pulmonary resections performed on 338 patients during a 5-year 
period. The emphasis in this study has been on important surgical com- 
plications, their management, and the problems peculiar to the mentally 
ill. (Surgery, June 1958; A. Mowlem, M. D. , et al. ) 

3[j :}: ^ sj: s}: ^ 



Medical News Letter, Vol. 32, No. 2 23 

Voluntary Retirement 

Retirement after 20 or more years of service has been authorized 
since 1955, and a number of Medical Department officers have been granted 
this early retirennent. It is felt that the availability of early retirement is 
a distinct addition to the attractiveness of a Navy career. 

iVhile general information on voluntary retirement appears to be wide- 
ly distributed, letters and comments received indicate that some of the details 
are less widely loiown. The specific criteria prescribed by the Secretary of 
the Navy as nneriting favorable consideration for early retirement are stated 
in SecNav Inst. 1811. 3A Of 10 September 1955, and anyone thinking of making 
such a request should be fully acquainted with this instruction as well as Bu- 
Pers Inst. 1811. lA of 19 July 1957. 

Among the six criteria listed is that of five years' service in grade 
for captains as well as 20 years' total service. Other of the listed criteria 
may be applicable to individual cases. Requests are considered on a basis 
of the over all needs of the Service and the merits of the individual case. 

Requests should be submitted at least three months and not more than 
six months ahead of the desired date, and the preretirement physical must 
be reported from one to three nnonths in advance, BuPers requires that 
officers starting a new tour of duty complete at least one year at the new 
station before voluntary retirement is effected. 

Obviously, an unexpected request for retirement creates problems 
in connection with a relief, and in some instances insufficient tinne has been 
allowed in which to arrange for a relief. Consequently, it is most desirable 
that BuMed be infornned of prospective retirement plans as far as possible 
in advance of the prescribed three months lead time to insure that the de- 
sired retirement date can be met. 

The Bureau is in no sense urging officers to consider early retire- 
ment. This note is simply to urge those who may be thinking of early 
retirement to become familiar with the requirements and proper procedure 
as detailed in SecNav and BuPers Instructions. {PersDiv, BuMed) 

H^ ^ >!; ;|i: iii iff. 

Postgraduate Short Courses for Naval Medical 

Department Officers - Sponsored by 

the U. S. Army 

The following postgraduate short courses will be given during fiscal 
year 1959 as indicated below. Eligible officers are those v-/ho meet the 
criteria prescribed by BuMed Instruction 1520. 8 of 6 February 1956. 

Eligible and interested officers should forward requests via official 
channels, addressed to the Chief of the Bureau of Medicine and Surgery. 
Requests for attendance must be received in Bureau of Medicine and Surgery 



24 



Medical News Letter, Vol. 32, No. 2 



at least 6 weeks prior to commencement of the course requested. Travel and 
per diem orders chargeable against Bureau funds will be authorized those 
approved for attendance. 



Course 

Management of Mass 
Casualties 



Location 

Walter Reed Army Institute 
of Research, Walter Reed 
Army Medical Center 



Dates 



15-20 Sep 1958 



Eleventh Annual Sym- 
posium on Pulmonary 
Diseases 



Army Medical Service School, 28 Jui~l Aug 1958 
Brooke Army Medical Center 22-26 Sep 1958 

27 Apr-1 May 1959 
15-19 Jun 1959 

Fitzsimons Army Hospital 8-12 Sep 1958 

(ProfDiv, BuMed) 



>[c >!= >|£ :>'f 



Postgraduate Short Courses for Naval Medical and Dental 
Officers - Sponsored by the U. S. Army and the 
Armed Forces Institute of Pathology 

The follovi/ing postgraduate short courses will be given during fiscal 
year 1959 as indicated below. Eligible officers are those who meet the 
criteria prescribed by BuMed Instruction 1520. 8 of 6 February 1956. 

Eligible and interested officers should forward requests via official 
channels, addressed to the Chief of the Bureau of Medicine and Surgery. 
Requests for attendance must be received in BuMed at least 6 weeks prior 
to comnnendement of the course requested. Travel and per diem orders 
chargeable against Bureau funds will be authorized those approved for 
attendance. 



Course 



Location 



Dates 



Corps 

Eligible 



Forensic Path- Armed Forces Institute of 6-11 Oct 1958 

ology Pathology 

Application of Armed Forces Institute of 27-31 Oct 1958 

Histochemistry Pathology 
to Pathology 

Ophthalmic Path- Armed Forces Institute of 9-13 Mar 1959 

ology Pathology 



MC 



MC 



MC 



Medical News Letter, Vol. 32, No. 2 25 

Corps 
Course Location • Dates Eligible 

Pathology of the Armed Forces Institute of 23-27 Mar 1959 MC, DC 
Oral Regions Pathology 

Cardiovascular Armed Forces Institute of 6-10 Apr 1959 MC 

Pathology Pathology 

Seminar (ProfDiv, BuMed) 

>[c ;^ -V. -I- 'i- -r- 

Vacancies in First Year Residencies in Specialties 
of Allergy and Otolaryngology to 
Commence in 1958 

Two vacancies now exist for first year level residency trainingj one 
vacancy in each of the specialties of Allergy and Otolaryngology, at the U. S. 
Naval Hospital, San Diego, Calif., to commence at the earliest possible date 
or during late summer or fall 1958. Applicants for training in Allergy should 
have had at least one or preferably tv,/o years of training in Internal Medicine. 

Applications should be made by an official letter addressed to the Bureau 
of Medicine and Surgery and forwarded via the chain of command, in accor- 
dance with BuMed Instruction 1520. 10 of 11 February 1957. Applications must 
contain the Service agreement to serve one year for each year of training 
received. See enclosure (1) to the above mentioned instruction. Approvals 
of Reserve officers will be contingent on applying for, and accepting, a com- 
mission in the Medical Corps of the Regular Navy, BuPers Instruction 1 120. 3E 
applies. (ProfDiv, BuMed) 

Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md, , giving full name, rank, corps, and old and new 
addresses. 

Use of funds for printing this publication has been approved by the 
Director of the Bureau of the Budget 19 June 1958. 

^ ¥ ^r ir V V 



26 Medical News Letter, Vol. 32, No. 2 

Recent Research Reports 
Naval Dental Research Facility, NTC, Bainbridge, Md . 

1. Microscopic Study of Saliva Sediment. NM 75 01 26,06, 1 March 1958. 

2. Survey of Dental Health of the Naval Recruit. II Survey of Dental Treat- 
ment. NM 75 01 26.04. 03, 1 May 1958 

3. Electrophoresis of Saliva. II Reproducibility, NM 75 01 26.05.02, 2 May 
1958. 

Naval Medical Research Institute, NNMC, Bethesda, Md . 

1. Effect of Exposure Geometry and Beam Spectrum on Depth-Dose Patterns 
for Penetrating Ionizing Radiation in Large Mammals and Man. NM 62 02 00 
.01.02, 26 November 1957. 

2. Development of Trypanosoma Lev./isi in the Heterologous Mouse Host. 
NM 52 02 00.01.01,23 December 1957. 

3. The Dissinnilation of Carbohydrates by Shigella Flexneri 3, NM 52 04 00 
.02.04, 30 December 1957. 

4. Hexitol Utilization by Shigella Flexneri. NM 52 04 00. 02. 02, 30 Decem- 
ber 1957. 

Naval Air Development Center, Johnsville, Pa. 

1. Erythrocyte Hydration under Positive Acceleration. NM 19 02 12. 1, 
Report No. 1, 7 April 1958. 

2. Variation in Duration of Oculogyral Illusions as a Function of the Radius 
of Turn. Report No. 2, NM 18 01 12.2, 22 May 1958. 

3. Relationship between Pain and Tissue Damage Due to Thermal Radiation. 
Report No. 15, NM 19 01 12.1, 11 June 1958. 

Naval Medical Field Research Laboratory, Camp Lejeune, N. C. 

1. Hepatic Function Following Flash Burn. 61 01 09. 1-8, March 1958. 

2. Acute Blood Volume Changes Following Flash Burn. NM 61 01 09. 1.9, 
March 1958. 

Naval Medical Research Laboratory, Submarine Base, New London, Conn. 

' I - ■ 1 1. 1. fc_ , . I ■ . .... i. . . i I I I I ^ I 

1. Evaluation of the Radarange for Subnnarine Use. Report No. 293, NM 24 
01 20 .04.02, 22 December 1957. 

2. Evaluation for Service Use of a Prototype Swimnner's Rescue Suit. NM 21 
01 20.01.01, Memorandum Report No. 58-1, 10 March 1958. 

(To be continued in an early issue) 



Medical News Letter, Vol. 32, No. 2 



27 



DEMTAL 




SECTIOIV 



Greetings from the Surgeon General on tiie 
46th Anniversary of the Dental Corps 

Rear Admiral B. W, Hogan MC USN, the Surgeon General of the Navy, 
addressed the following letter to Rear Admiral R. W. Malone DC USN, Assistant 
Chief for Dentistry and Chief, Dental Division, Bureau of Medicine and Surgery; 

"Rear Admiral R. W. Malone (DC) USN 
Assistant Chief for Dentistry 
and Chief, Dental Division 
Bureau of Medicine and Surgery 
Navy Department 
Washington 25, D. C. 

Dear Admiral Malone: 



It is a pleasure for me, as Surgeon General, to extend my sincere congrat- 
ulations to you and to every menmber of the Dental Corps on this occasion 
of the forty -sixth anniversary of the founding of the U. S. Navy Dental Corps. 

The Dental Corps has been noted for its progressive effectiveness ever 
since it was established on 22 August 1912 by the provision of the Naval 
Appropriation Act which authorized the appointment of 'not more than thirty 
assistant dental surgeons ... to serve professionally the personnel of the 
Naval Service. ' During the past forty -six years the Navy Dental Corps has 
been an important member of our Navy health team. The Dental Corps has 
justly earned its reputation for being a successful organization. The Bureau 
is especially proud of the initiative shown recently by the Dental Corps in 
the fields of developing high-speed operative dentistry techniques and in 
developing a program to train dental personnel to care for mass casualties. 
Of course, the most important acconnplishment of the Dental Corps has been 
the excellent level of dental care which its members have provided to person- 
nel of our Navy and Marine Corps. I am especially proud of the effective man- 
ner in which dental care has been extended to overseas dependents during the 
past year, as authorized by the Dependents' Medical Care Act. 



28 Medical News Letter, Vol. 32, No. Z 



On this forty- sixth anniversary, I also wish to extend my congratula- 
tions to the Dental Technicians, Dental Service Warrant Officers, and 
Medical Service Corps Officers, whose skill and loyalty have contributed 
so much to the accomplishments of the Navy Dental Service. 1 join all of 
you in looking forward with confidence to many more years of successful 
achieveniients. 



Anniversary best wishes. 



Sincerely, 

/s/ 

B. W. Hogan 

Rear Admiral, MC USN 

Surgeon General" 

^ ;{;:{: ^ ;^ :j<: 

Practical Methods for Good Dental X-Ray Practice 

Check the Dental X-Ray Machine . Use only modern, well shielded 
equipment. Obsolete equipment is likely to be dangerous both electrically 
and radiologically and should be discarded, particularly old units with open 
tubes. The modern high kilovoltage machines are preferable. Dental x-ray 
equipment should be used for dental radiography only — it is not designed 
for other purposes. 

Use the Proper Diaphragm or Cone . The apparatus should be tested 
to be sure that there is no appreciable leakage radiation emerging through 
any other part of the tube housing or the diaphragm or cone margins. The 
proper diaphragm or cone limits the primary beam to a circle of 3 inches 
diameter at the tip of the cone. If this must be removed for a special 
purpose, such as examination of the tern poro -mandibular joint, the regular 
cone or diaphragm should be replaced before subsequent conventional use. 

Use the Proper Filter . Make certain that the filter is always in place. 
It should be at least 1.5 mm. of aluminum in machines which operate up to 
80 KVP and at least 2. mnm. of aluminum in machines which operate above 
80 KPV. 

Measure the Output of the Machine. The radiation output of the mach- 
ine should be known under the conditions of kilovoltage, filter, and distance 
used. 

Maintain Adequate Radiation Protection for Operating Personnel. All 
personnel should stay well away fronn the primary beam. The operator 
should never hold the dental film, the pointer cone, or tubehead, during 
exposure. The use of handheld fluoroscopic screens is dangerous and should 



Medical News Letter, Vol. 32, No. 2 2*^ 



be strictly avoided. The timer control cord should be long enough to allow 
the operator to stand behind an adequate protective barrier. When this 
cannot be arranged, the operator should stand at least 5 feet away from 
the tube and well away from the primary beann. Filnn badges are recom- 
mended for monitoring of personnel exposure. They should be of the type 
designed and processed for this purpose; ordinary dental films with a paper 
clip or coin are not satisfactory for this purpose. 

Check the Radiation Protection of the Room Installation. The safety 
of adjacent areas from both primary and secondary radiation should be 
assured with protective barriers and distance as specified in National Com- 
mittee on Radiation Protection Handbook #60 and applied to the particular 
installation. It is good practice to rotate the dental chair so that the patient 
faces away from the room window during exposures, as this directs the pri- 
mary beann toward an outside wall. 

Use Fast Film, Good Exposure, and Processing Technique. The rad- 
iation exposure of patient and personnel can be greatly reduced by using 
high kilovoltage, adequate filters, and modern fast film. The longest target 
to film distance that is practicable should also be used. The optimum ex- 
posure times for these factors should be carefully determined and used 
regularly. All film processing should be done with exact tinne and temper- 
ature control, using fresh and good solutions. Attention to these points 
will give the best quality films and will reduce the need for reexaminations 
with their attendant additional radiation exposure. 

Protect the Gonads of the Patient. Whenever possible, direct the 
primary beam away from the region of the gonads. This can often be 
achieved by appropriate tilting of the patient's head. Some additional re- 
duction in primary or scattered radiation can be obtained by placing pro- 
tective material, such as a lead rubber sheet or apron, across the patient's 
lap. This is particularly useful when multiple exposures are necessary or 
in special instances, such as children and pregnant women or when the 
primary beam cannot be directed away from this area. 

Consider the Indications for Each Examiination Perform ed. Is is good 
practice to do a limiited examination first . This preliminary survey will 
often provide all of the necessary information. Additional film exposures 
can then be decided upon as specifically required. " Routine" extensive 
surveys and frequent reexaminations should be avoided whenever possible . 

Use Special Care with Children and Pregnant Women . The number 
of exposures to children should be restricted to an absolute minimum from 
both somatic and genetic considerations. The extra hazard of exposure to 
pregnant wonaen. calls for postponing complete or elaborate procedures as 
n:iuch as practicable during this period. (Chamberlain, R. H. , Nelson, R. J, , 
prepared by the American College of Radiology - A Practical Manual on 
the Medical and Dental Use of X-Rays with Control of Radiation Hazards) 

T ^F T- '5^ ^ T^ 



30 Medical News Letter, Vol. 3Z, No. 2 




RESERVE SECTIOIM 



Reserve HC Division Participates 
in Operation Alert 

At 0800 hours on 6 May 1958, members of Naval Reserve Hospital 
Corps Division 4-2 Pittsburgh, Pa. , commenced, participation in operation 
"Prep Pitt" which was developed as a simulated training exercise under the 
nationwide "Operation Alert. " 

Under the joint sponsorship of the Allegheny County Medical Society 
and Hospital Council of V/e stern Pennsylvania, the operation was conducted 
in cooperation with the Medical Education for National Defense Program of 
the University of Pittsburgh School of Medicine, the Office of Civil Defense, 
City of Pittsburgh, the Pittsburgh Chapter of the American Red Cross, and 
the Veterans Administration Hospital, Pittsburgh, where casualties were 
received and treated. 

Designed and planned to demonstrate problems associated with a modest 
disaster, operation "Prep Pitt" was based on 50 casualties who were survivors 
of an explosion and fire following a crash of a jet aircraft on the University 
of Pittsburgh Field House. The "injured" included patients suffering from 
burns, soft tissue injuries, cavity injuries, and fractures. All were moved 
to the Veterans Administration Hospital. 

After 7 hours continuous drill, the exercise was completed at 1500. 
For their vigorous and effective performance of tasks assigned, members of 
Hospital Corps Division 4-2 were commended by both the staff of the Veterans 
Administration Hospital and officials assigned to umpire the operation. 

In addition to evolving a more effective disaster plan and providing 
excellent training for care of mass casualties, recruiting of new members for 
the unit has been stimulated. 

A salute to L.T E. E. Longabaugh MC USNR, Con^manding Officer, and 
the members of 4-2 for their efforts in this laudable undertaking. 

=;: 5^ s5: ^ Jic >|i 

Military Industrial Vision Seminar 

The California Optometric Association will conduct a Military Indus- 
trial Vision Seminar at the Lafayette Hotel, Broadway and Linden Avenues, 
Long Beach, Calif. ,28-29 August 1958. 



Medical News Letter, Vol. 32, No. 2 31 



The Chief of Naval Personnel has authorized retirement point credit 
to Reserve Medical Department officers for daily attendance providing 
they register with the authorized military representatives present. Par- 
ticipation in this seminar offers an excellent opportunity for Medical Depart- 
ment officers to be brought up to date in the latest developnnents of indus- 
trial optometry. 

;/fi :i: ^ :i: ^f ^ 

Treatnnent of Chemical Warfare Casualties 

The Medical Department correspondence course, Treatment of Chem- 
ical Warfare Casualties, NavPers 10765, is available to Regular and Re- 
serve officers and enlisted personnel of the Medical Departnnent of the 
Armed Forces as well as officers of the U.S. Public Health Service and 
allied foreign medical department officers. 

Modern chemical warfare began with the use of chlorine gas by the 
German Army in 1915. This new kind of warfare had a psychological effect. 
Coupled with misleading propaganda and a lack of Itnowledge of the specific 
chemical agents used, it resulted in unfounded fear in the troops and mis- 
diagnoses by medical personnel. As a result of better understanding of the 
physiological and psychological effects of chemiical warfare agents, mil- 
itary personnel are now better equipped to cope with gas attacks than were 
military personnel in the past. 

The purpose of this course is to provide personnel with innportant 
self-aid techniques for battle field treatnnent of chemical warfare injuries 
and to assist the enrollee in explaining these techniques to individuals who 
may encounter gas warfare situations. The course also describes methods 
of detecting and identifying agents, techniques of identifying casualties and 
noncasualties, and methods of protecting personnel prior to exposure to 
chemical agents. The physiological and psychological effects of each agent 
are discussed, together with the reconnmended treatment for each. In the 
event of a future chemical warfare situation, personnel who have completed 
this course will be aware of the important self-aid techniques for battle- 
field treatnnent of chemical warfare injuries. Knowledge of the properties 
and effects of these agents will assist personnel in the prevention of danger- 
ous psychological effects on military personnel. 

The course consists of three (3) objective type assignments and is 
evaluated at nine (9) Naval Reserve promotion and/or nondisability retire- 
ment points. Applications for this course should be forwarded on NavPers 
992 (Rev 1/57) via applicant's command to Comnnanding Officer, U.S. Naval 
Medical School, National Naval Medical Center, Bethesda 14, Md. Make 
appropriate change in the "To" line in Box J of the application form. 
Note : Medical Department Reservists may enroll in more than one MD 
correspondence course at one time. 



32 Medical News L, tter, Vol. 32, No. 2 




'^PREVEIVTIVE MEDICIJVE SECTIOIV 



Seat Belts in. Actual Crashes 

Automobile seat belts have chalked up an amazing record for taking 
the stress of accident crashes. Cornell University's Automotive Crash 
Injury research has found that only 11 seat belts involved in 511 accident 
cases studied failed to function as intended, A total of 712 belts was in- 
volved in the 511 accident cases processed. 

The researchers observed that, even in the 11 cases of misfunction, 
the failure to operate as intended could not always be ascribed to structural 
deficiencies of the belts themselves. Here is a brief description of the types 
of failure followed by some actual case histories: 

Webbing Failure. Among the 11 cases, there were 4 in which the webbing 
parted. Two of these were clear-cut cases in which the webbing of a 
relatively new belt failed to stand up under impact. In a third case, the 
webbing which parted had been in use for 9 years prior to the accident 
and the failure can probably be ascribed to normal deterioration with age. 
In the fourth case, both the webbing and the floor attachnnent were repor- 
tedly "ground to pieces" by direct inapact vvhen a large tree innpacted at 
some 50 mph penetrated the passenger compartment. 

Case : A 1954 Austin sport roadster missed a curve and crashed into 
a tree 24 inches in diameter. Traveling speed prior to accident was 
70 mph and at impact about 50 mph. The point of impact was the right 
front side just ahead of the door. The accident is classed an ''non- 
survivable" for the right front seat occupant, with or vvithout safety 
belt. The right front passenger was thrown out when his belt failed. 
Fatal skull fracture was ascribed to impact with pavement when 
ejected. The driver suffered lacerations of the scalp and right eyelid 
(windshield), a bruised chest (steering assennbly), and contusions of 
right elbow, right hip, left ankle, and chin. 

B uckle Slippage . Of the two cases where belts slipped through the buck- 
les, one was a case in which the trooper reported that 'the belt was im- 
properly threaded into the buckle. In the other, a trooper reported that 



Medical News Letter, Vol. 32, No. 2 33 



his own buckle failed to hold when his weight was thrown against it, but 

did not specify whether it was properly engaged. 

Case: The front end of the case car, a 1954 Tudor Ford, struck the 
side of a 1946 Chevrolet pickup truck. Speed of case car, 40 mph. 
Speed of truck, 30 mph. Driver states that buckle did not hold when 
his weight was applied against it, but nevertheless, felt that the belt 
did afford some protection. Belt was attached at floor. Driver suf- 
fered bruises and contusions to right knee which struck dashboard. 
No passengers. 

Anchorage Failure . Two cases were reported, one of which also involved 
parting of the webbing. In both cases, there was considerable evidence 
that the anchorages were sheared off by direct impact when obstacles 
struck penetrated the passenger compartment. Both were cases in which 
there was some question as to whether the accident was technically a 
"survivable accident, " because the passenger compartments of the cars 
involved were extensively damaged. 

Case: The case car, a 1953 Studebaker tvv/o-door sedan, attempted 
to dodge a 1947 Plymouth two-door sedan which was on the wrong 
side of the road. Speed of the case car was 55 mph. Speed of other 
car prior to impact was 55 mph, at incipact, 50 mph. The left front 
half of the Plymouth plowed along the right side and penetrated the 
rear seat area. When the floor attachment of the right front passen- 
ger's belt tv./isted and broke off, he fell against the glove compartment 
and toppled out of the car. He suffered deep laceration on right shoul- 
der (glove compartment), minor facial abrasions and contusion of 
right hand (cause unknown), and contusion of the kidney and hematuria 
(inside or outside car). The driver suffered a four-inch scalp lacer- 
ation (windshield) and bruises on chin (upper steering wheel). 

Buckled Floor Pan. In one case, although the belt held, the floor pan 
to which it was attached buckled upward about six inches. This is clearly 
not a case of belt failure, but does indicate the importance of considering 
the strength of structures to which belts are to be attached. 

Case: The left front third of the case car, a 1950 Plymouth 2 -door 
sedan, struck a tree about one foot in diamieter. Car turned over on 
its left side. Speed prior to, and at, impact was 50 mph. Left front 
door opened at impact. The driver suffered bump on forehead {steer- 
ing wheel), miinor cuts on face (flying glass), bruised left elbow (door 
structure), and bruised left ankle (pinched by seat). There were no 
passengers. 

Webbing Slipped out of Anchorages. Two cases, both in the same car, 
were reported. The anchorages were of the triple -slot variety, where 



34 Medical News Letter, Vol. 32, No. 2 



the belt is threaded in a precise pattern through the aeries of slots, and 
held by friction. Because there are numerous cases on record where 
such attachments have held, but because the threading pattern must be 
precisely followed to hold properly, it is at least possible that in this 
case the belts' ends were improperly threaded. This appears especially 
likely since the two cases of failure were in the sanne car, and the two 
belts were probably threaded by the same person. 

Case: The case car, a 1955 Ford tudor sedan, traveling at 79 mph, 
went out of control on the right shoulder, then swerved back across 
the highway into oncoming lane. A 1956 Oldsmobile, two-door sedan, 
traveling at 55 mph ran into the right fender of the case car. Both 
cars spun around and left the highway. Doors of case car opened and 
right front passenger was ejected and killed from injuries sustained 
outside the car {broken neck, unspecified head injuries, fractured 
left femur). The driver suffered a fractured right arm and lacerated 
right hand (cause unknown). 

Special Circumstances. In one case, where design was such that the outer 
strap of the belt was attached to the door, some slack was caught between 
the door and the seat by mistake. When the door came open, the belt no 
longer fimctioned as a seat belt, but became in effect merely a door strap. 
Although the belt remained structurally intact, the occupant was readily 
ejected. (Traffic Safety, 52: 10-12, June 1958) 

^ :Je >|< >}: j[: >fr 

Possible Transmission of Poliomyelitis 
by Domestic Pets 



Although numerous animals, including dogs, cats, and even moles, 
have been named as possible reservoirs of poliomyelitis virus, confirm- 
atory evidence from laboratories has always been lacking. Possible avian 
reservoirs were suggested when a time relationship was observed between 
outbreaks of fowl paralysis and the human poliomyelitis epidemic in South 
Africa in 1948, but no association was proved. 

An incident is described by Dr. R.G. Somnnerville and his associates 
(The Lancet, March 8, ,1958) in which there seems little reason to doubt 
that a budgerigar (Australian parakeet} became infected with poliovirus 
type 1 and excreted this virus for at least 3 weeks. Again, attention is 
drawn to the possibility of transmission of poliomyelitis by domestic pets. 

A budgerigar recovering from paralysis of its legs bit a boy on the 
lip, holding on with its beak until it was removed by the boy's mother. 
Another bird which had been kept in the same cage had died from a similar 



Medical News Letter, Vol. 32, No. 2 35 



attack of paralysis a few days earlier. A week after the bite, the child devel- 
oped signs of bulbar poliomyelitis and subsequently died. Type 1 poliovirus 
was recovered from his stool. 

A possible association between the bird's bite and the boy's illness 
led to an examination of the bird's droppings which were found to contain 
type 1 poliovirus. A second sannple of droppings and of the bird's intes- 
tinal contents, recovered after sacrifice of the budgerigar 3 weeks later, 
yielded the same findings. 

The viruses were identified by neutralization tests in HeLa cells using 
high-titer antiserum prepared in monkeys against standard strains of polio- 
virus types 1, 2, and 3, No difficulty was experienced with the neutralization 
tests and the viruses behaved like any other strains of poliovirus type 1. 

To exclude the possibility that the monkey antiserum to poliovirus 
type 1 which was used to identify each virus contained additional antibody to 
an agent other than poliovirus, a rabbit antiserum was prepared against the 
virus isolated from the intestinal contents of the bird at necropsy. The rab- 
bit antiserum neutralized the standard strain of poliovirus type I (Mahoney) 
maintained in this laboratory and also neutralized each virus isolated from 
the budgerigar. The antiserum did not neutralize either type 2 or type 3 
poliovirus. 

A similar case is recorded (Dublin City Health Dept. , 1956) involving 
a household in which a child developed paralytic poliomyelitis (poliovirus 
type 1 found in feces) and in which 23 canaries had died about the sanne time. 
No leg paralysis had been observed in any of the birds, and there was no 
history that the child had been pecked by the canaries, but had played in the 
room where they were caged. No laboratory examination was made of ex- 
creta from these birds. 

Heretofore it has been thought that under natural conditions no animal 
other than man becomes infected with poliomyelitis. This opens a whole 
new field for speculation and research in regard to poliomyelitis virus. An 
explanation of the seasonal appearance of poliomyelitis may come through 
discovery of a reservoir for the virus during the months of low incidence. 

(CommDis, PrevMedDiv, BuMed) 

Jl! :{t sj; ^ sic sjc 

Ecology of Equine Encephalomyelitis 

This article sunnmarizes a series of field investigations which con- 
stitute a continuation and geographic extension of previous studies. The data 
consist of the results of virus isolation and serum neutralization tests on 
wild bird blood collected in Louisiana, Alabama, New Jersey, and Massa- 
chusetts, //hen the results of studies made on eastern equine encephalomye- 
litis (EEE) in wild birds in different localities over the course of several 



36 Medical News Letter, Vol. 32, No. 2 



years are summarized, two differing patterns of activity appear to pre- 
vail. The first pattern appears to be the progression of the virus through a 
wild bird population at a normal endemic maintenance rate. This appears to 
have been the case in Louisiana in 1952, 1953, and 1956, and in Massachu- 
setts in 1953. Also it presumably was the case in New Jersey in 1955 and 
in Alabama in 1956 as indicated by the residual immunity rates observed 
early the following year. Under these conditions, it was possible to isolate 
virus from less than 1% of the birds collected and 13 to 22% of the population 
were found to possess neutralizing antibody. Very little or no human or 
horse involvement occurred in any of these areas during the years mentioned. 
Such a level of activity would seem to favor the continued presence of the 
virus. 

A second pattern of activity of EEE virus in wild birds was observed 
in two different localities in New Jersey and also in Massachusetts during 
1956, and in Alabama in 1957. Also it may be presumed to have occurred in 
Louisiana in 1955 on the basis of the 54% immunity rate observed in the March 
1956 collection. A similar situation appears to have been present in New 
Jersey in 1953. On these occasions the virus seems to have spread through 
the wild bird population with explosive speed. Bird species, such as Eng- 
lish sparrows and domestic pigeons which are not involved in the endemic 
sylvan cycle became involved. On several occasions, virus was isolated 
from as high as 11% of the birds in a day's collection and this activity was 
seen to result in the immunity of 45 to 54% of the population. Such a level 
of immianity would seem to jeopardize the continued presence of the virus. 
The virus also appeared outside its usual geographic limits and on all of the 
instances mentioned, equine s were involved in epidemic proportions. Human 
cases of EEE occurred in Louisiana in 1955 and in Massachusetts in 1956. 
EEE epidemics also occurred in ring-necked pheasants in New Jersey in 
1953 and 1956, and in Massachusetts in 1956. 

Such hyperactivity also seems to have occurred with western equine 
encephalomyelitis (WEE) virus in Louisiana in 1952, and in New Jersey in 
1956. However, the over all rate of activity of WEE in the eastern United 
States seemis to be lower than that of EEE, n:3inimizing the importance of 
such occurrences proportionately. 

The ecologic balances which hold the activity of EEE virus to a level 
compatible with its survival in appropriate areas are not well understood. 
However, it seems logical to conclude that its maintenance depends on suf- 
ficiently susceptible bird populations of appropriate density and upon a vector 
population of proper transmitting efficiency and also at an optimum density. 
These balances may be upset, conceivably by great increases in numbers of 
either birds or the usual vectors. It is more probable, however, that it is 
the entrance into the transmission cycle of other highly efficient mosquito 
species in large numbers which produces an epidemic situation. 

Conditions seenn to be well established for the maintenance of these 
viruses in the eastern United States and to be of such longstanding and wide 



Medical News Letter, Vol. 32, No. 2 37 



occurrence that their eradication from nature is probably impossible or 
impractical. On the other hand, an imder standing of the factors responsible 
for these sudden presumably abnormal bursts of virus activity nnay enable 
-workers to predict epidemics or to detect them in their incipient stages, 
and possibly prevent the involvement of man or domestic animals. (Stamm, 
D. D. , V. M. D. , t Studies on the Ecology of Equine Encephalomyelitis: Am. 
J. Pub. Health, 48_: 328-335, March 1958} 
• 

>ic $ ^ lie :^ sic 

Fires and Explosions in the Operating Room 

Fires and explosions have occurred in conjunction with the use of flam- 
mable anesthetics since their introduction. Has the problem of preventing 
fires and explosions in the operating room gradually become more complex? 
The answer is definitely "yes" and the reasons are not hard to find. The 
increased number of operations and the greater length of many of them have 
multiplied the hours during which fires and explosions might occur. A host 
of electrically operated pieces of apparatus, such as cauteries, suction 
pumps, electrosurgical, electrocardiographic, and electroencephalographic 
units, photographic equipment (movies and television apparatus) have found 
their way into the operating room. Also the increased number of individuals 
in the operating room has multiplied the chances for the ignition of flammable 
mixtures by static sparks. The surgical invasion of all compartments of the 
body (chest, heart, brain) and the performance of radical surgery therein 
so often requiring the use of electrosurgical equipment have made imprac- 
tical the attempt to keep the surgeon and his dangerous equipment at a "safe 
distance. " Do we have a solution to the problem of fire and explosion in 
the operating room? No, not completely, but progress has been made and 
much can be done to decrease this hazard. 

Flamnnable nnixtures require an ignition source for an explosion to 
occur. These sources of ignition can be divided into four general groups: 
(1) direct contact with open flame or hot bodies, (2) sparks from electrical 
power circuits, (3) electrostatic discharge, and (4) spontaneous combustion. 

The personnel should have basic initial instruction and periodic re- 
fresher sessions to remind them of the many hazards that exist in the oper- 
ating room. The desirability for them to realize the iniportance of the 
danger zone which exists at the head of the table while flammable anesthe- 
tics are being administered cannot be overemphasized. A philosophy of 
slow, deliberate motion should be established — particularly annong anesthe- 
siologists. An electrostatic charge can accumulate only when the rate of 
generation exceeds the rate of dissipation over the conductive pathway. 
Slow motion in the hazardous area becomes an innportant safeguard when 
contact with the conductive pathway is marginal. 



38 Medical News Letter, Vol. 32, No. 2 



Dangerous fabrics must not be worn. Freshly laundered cotton with 
an adequate moisture content is essential for electrostatic control. The 
buildup of electrostatic charge on wool and synthetic cloth is so rapid that 
these materials are outlawed unless the entire garment is worn in direct 
contact with the skin which serves as a leakage path for the dissipation of 
the charge. For example, nylon hose present little hazard once the soles 
are moistened with perspiration; a petticoat, however, is dangerous be- 
cause the free hanging skirt becomes charged through motion. Synthetic 
material is such a good insulator that the charges remain even though the 
bodice is in contact with skin. There nnust be personal responsibility for 
maintenance of a conductive contact with the floor. Conductive sole shoes, 
conductive booties or slip-ons are effective only when they are properly 
worn. They nnust be tested daily because dirt that collects on the bottom 
may destroy the electrical contact. A testing device and an inverted 
brush fixed to the floor should be standard equipnnent at the entrance to 
every operating room corridor so that faulty contact can be detected and 
corrected. Because dirt interferes with the electrical contact, personnel 
must be trained to keep the floors clean. , The surgeon who discards suture 
ends to the floor, the nurse who drops broken glass or fails to clean up 
blood or pus before it is tracked about, contribute to the hazard. (Nicholson, 
M. J. , Orr, R. B. , Fire and Explosion Hazards in the Operating Room: Surg, 
Clin. N. America, June 1957: Abstracted in J. A. M. A. l67 : 52, May 10, 1958) 

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Formulas for Newborn Infants 

The preparation of baby formulas is a relatively simple task which 
can be performed by any well trained careful hospital corpsman. 

A baby's forinula should be as sterile as humanly possible to pro- 
vide. Bacteriologic examination should be performed at least once a week. 
The plate counts on random samples of bottled forn^ula should not exceed 
25 organisms per niilliliter. Generally prescribed formulas of either 
evaporated milk or sterile powdered milk permit this standard to be main- 
tained without difficulty, if the proper method of terminal heating is ob- 
served. 

An authoritative guide for formula preparation, Standards and Recom - 
mendations for Hospital Care of Newborn Infants, published by the American 
Academy of Pediatrics, 610 Church Street, Evanston, 111. , is available at 
$1.50 per copy. (Sanitation Section, PrevMedDiv, BuMed) 

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Medical News Letter, Vol. 32, No. 2 39 



Statement on Prophylaxis of Ophthalmia Neonatorum 

On January 25, 1955, the Committee on Fetus and Newborn reviewed 
the problem of prophylaxis of gonorrheal ophthalmia in the newborn infant 
with particular reference to the possibility of changing the standing recom- 
mendations for instillation of 1% silver nitrate. The review of available 
information indicated: 

1. That no evidence existed that damage to the eyes has followed 
the use of 1% silver nitrate when used as recommended. 

2. That use of various antibiotics (penicillin, erythromycin) instead 
of silver nitrate did reduce the incidence of nonspecific conjunctivitis. 

3. That the ajitibiotics used in controlled studies apparently were as 
effective in preventing gonorrheal ophthalmia as was silver nitrate, 

e. g. , no cases were reported in either group. 

The Committee was concerned with the possible occurrence of sen- 
sitization to locally administered antibiotics, the possible emergence of 
antibiotic resistant strains of bacteria, and possible difficulties in main- 
taining stability and potency of antibiotic preparations under hospital sto- 
rage conditions. Furthermore, the Committee was aware of studies in 
progress in which no routine prophylaxis was carried out. In view of 
these considerations, the Committee on Fetus and Newborn did not recom- 
mend any change in the existing procedure for the prevention of gonorrheal 
ophthalmia. 

On February 8, 1958, the Committee again reviewed the problem in 
light of additional information; 

1. In a large metropolitan hospital, elimination of eye prophylaxis 
of any type resulted in the occurrence of 4 cases of gonorrheal ophthal- 
mia within 4 months. Significantly, none of the others had given any 
evidence of disease eind one of the babies developed conjunctivitis after 
discharge from the hospital. This hospital had had no cases of gonor- 
rheal ophthalmia since the institution of silver nitrate prophylaxis. 

2. In a study from Australia, babies receiving no prophylaxis demon- 
strated as high an incidence of discharging eyes as did babies receiving 
silver nitrate. Furthermore, babies receiving no prophylaxis demon- 
strated a higher incidence of pathogens on culture (nongonococcus) than 
did the babies receiving silver nitrate. The most common organism 
found in both groups was staphylococcus aureus. 

3. Various prophylactic measures were considered in the context of 
the problem of antibiotic resistant infections in newborn nurseries to- 
gether with the fact that the organisms commonly found in the eyes of 
newborn infants have very limited sensitivity to currently available 
antibiotics. 

OV. S. aOVEHNMENT PRINTING OFFICE 1 1S5B O • (181495 



40 



Medical News Letter, Vol. 32, No. 2 



On the basis of available evidence, the Committee believes: 

1. That gonorrheal ophthalmia still constitutes a definite hazard to 
the newborn infant. 

2. That silver nitrate has amply demonstrated its effectiveness as 
a prophylaxis of gonorrheal ophthalmia. 

3. That the occurrence of nonspecific conjunctivitis does not of itself 
constitute adequate reason for change. 

4. That the routine use of antibiotics may introduce further problems 
referable to control of infections in new born nurseries. 

Therefore, the Conamittee on Fetus and Newborn recommends that 
the routine use of 1% silver nitrate for prophylaxis of gonorrheal ophthal- 
mia be continued. (News Letter, American Academy of Pediatrics, Vol. 9, 
No. 3, March 1958; abstracted in Connecticut Health Bulletin, June 1958) 

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